AUDIT: the Alcohol Use Disorders Identification Test

WHO/MSD/MSB/01.6a Original: English Distribution: General

Thomas F. Babor John C. Higgins-Biddle John B. Saunders Maristela G. Monteiro

AUDIT

The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care

Second Edition

World Health Organization Department of Mental Health and Substance Dependence WHO/MSD/MSB/01.6a Original: English Distribution: General

Thomas F. Babor John C. Higgins-Biddle John B. Saunders Maristela G. Monteiro

AUDIT

The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care

Second Edition

World Health Organization Department of Mental Health and Substance Dependence 2 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Abstract

This manual introduces the AUDIT, the Alcohol Use Disorders Identification Test, and describes how to use it to identify persons with hazardous and harmful patterns of alcohol consumption. The AUDIT was developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking and to assist in brief assessment. It can help in identifying excessive drinking as the cause of the presenting illness. It also provides a framework for intervention to help hazardous and harmful drinkers reduce or cease alcohol consumption and thereby avoid the harmful consequences of their drinking. The first edition of this manual was published in 1989 (Document No. WHO/MNH/DAT/89.4) and was subsequently updated in 1992 (WHO/PSA/92.4). Since that time it has enjoyed widespread use by both health workers and alcohol researchers. With the growing use of alcohol screening and the international popularity of the AUDIT, there was a need to revise the manual to take into account advances in research and clinical experience. This manual is written primarily for health care practitioners, but other professionals who encounter persons with alcohol-related problems may also find it useful. It is designed to be used in conjunction with a companion document that provides complementary information about early intervention procedures, entitled “Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care”. Together these manuals describe a comprehensive approach to screening and brief intervention for alcohol-related problems in primary health care.

Acknowledgements

The revision and finalisation of this document were coordinated by Maristela Monteiro with technical assistance from Vladimir Poznyak from the WHO Department of Mental Health and Substance Dependence, and Deborah Talamini, University of Connecticut. Financial support for this publication was provided by the Ministry of Health and Welfare of Japan.

© World Health Organization 2001 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced, and translated, in part or in whole but not for sale or for use in conjunction with commercial purposes. Inquiries should be addressed to the Department of Mental Health and Substance Dependence, World Health Organization, CH-1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions and the reprints, regional adaptations and translations that are already available. Authors alone are responsible for views expressed in this document, which are not necessarily those of the World Health Organization. TABLE OF CONTENTS I 3 Table of Contents

4 Purpose of this Manual

5 Why Screen for Alcohol Use?

8 The Context of Alcohol Screening

10 Development and Validation of the AUDIT

14 Administration Guidelines

19 Scoring and Interpretation

21 How to Help Patients

25 Programme Implementation

Appendix

28 A. Research Guidelines for the AUDIT

30 B. Suggested Format for AUDIT Self-Report Questionnaire

32 C. Translation and Adaptation to Specific Languages, Cultures and Standards

33 D. Clinical Screening Procedures

34 E. Training Materials for AUDIT

35 References 4 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST Purpose of this Manual

his manual introduces the AUDIT, the The appendices to this manual contain TAlcohol Use Disorders Identification additional information useful to practi- Test, and describes how to use it to identify tioners and researchers. Further research persons with hazardous and harmful paton the reliability, validity, and implemen- terns of alcohol consumption. The AUDIT tation of screening with the AUDIT is was developed by the World Health suggested using guidelines outlined in Organization (WHO) as a simple method Appendix A. Appendix B contains an of screening for excessive drinking and to example of the AUDIT in a self-report assist in brief assessment.1,2 It can help questionnaire format. Appendix C pro- identify excessive drinking as the cause vides guidelines for the translation and of the presenting illness. It provides adaptation of the AUDIT. Appendix D a framework for intervention to help risky describes clinical screening procedures drinkers reduce or cease alcohol con- using a physical exam, laboratory tests sumption and thereby avoid the harmful and medical history data. Appendix E lists consequences of their drinking. The AUDIT information about available training also helps to identify alcohol dependence materials. and some specific consequences of harmful drinking. It is particularly designed for health care practitioners and a range of health settings, but with suitable instructions it can be self-administered or used by non-health professionals.

To this end, the manual will describe:

Reasons to ask about alcohol consumption The context of alcohol screening Development and validation of the AUDIT The AUDIT questions and how to use them Scoring and interpretation How to conduct a clinical screening examination How to help patients who screen positive How to implement a screening programme WHY SCREEN FOR ALCOHOL USE? I 5 Why Screen for Alcohol Use?

here are many forms of excessive Harmful use refers to alcohol consump- Tdrinking that cause substantial risk or tion that results in consequences to phys- harm to the individual. They include high ical and mental health. Some would also level drinking each day, repeated consider social consequences among the episodes of drinking to intoxication, harms caused by alcohol3, 4. drinking that is actually causing physical or mental harm, and drinking that has Alcohol dependence is a cluster of resulted in the person becoming depen- behavioural, cognitive, and physiological dent or addicted to alcohol. Excessive phenomena that may develop after drinking causes illness and distress to the repeated alcohol use4. Typically, these drinker and his or her family and friends. phenomena include a strong desire to It is a major cause of breakdown in rela- consume alcohol, impaired control over tionships, trauma, hospitalization, pro- its use, persistent drinking despite harm- longed disability and early death. ful consequences, a higher priority given Alcohol-related problems represent an to drinking than to other activities and immense economic loss to many commu- obligations, increased alcohol tolerance, nities around the world. and a physical withdrawal reaction when alcohol use is discontinued. AUDIT was developed to screen for excessive drinking and in particular to Alcohol is implicated in a wide variety of help practitioners identify people who diseases, disorders, and injuries, as well as would benefit from reducing or ceasing many social and legal problems5,6,7. It is a drinking. The majority of excessive major cause of cancer of the mouth, drinkers are undiagnosed. Often they esophagus, and larynx. Liver cirrhosis and present with symptoms or problems that pancreatitis often result from long-term, would not normally be linked to their excessive consumption. Alcohol causes drinking. The AUDIT will help the practi- harm to fetuses in women who are preg- tioner identify whether the person has nant. Moreover, much more common hazardous (or risky) drinking, harmful medical conditions, such as hypertension, drinking, or alcohol dependence. gastritis, diabetes, and some forms of stroke are likely to be aggravated even by Hazardous drinking3 is a pattern of alco- occasional and short-term alcohol con- hol consumption that increases the risk sumption, as are mental disorders such as of harmful consequences for the user or depression. Automobile and pedestrian others. Hazardous drinking patterns are injuries, falls, and work-related harm fre- of public health significance despite the quently result from excessive alcohol con- absence of any current disorder in the sumption. The risks related to alcohol are individual user. linked to the pattern of drinking and the amount of consumption5. While persons with alcohol 6 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

dependence are most likely to incur high in hazardous alcohol use. Given these levels of harm, the bulk of harm associat- factors, the need for screening becomes ed with alcohol occurs among people who apparent. are not dependent, if only because there are so many of them8. Therefore, the Screening for alcohol consumption identification of drinkers with various among patients in primary care carries types and degrees of at-risk alcohol con- many potential benefits. It provides an sumption has great potential to reduce all opportunity to educate patients about types of alcohol-related harm. low-risk consumption levels and the risks of excessive alcohol use. Information Figure 1 illustrates the large variety of about the amount and frequency of alco- health problems associated with alcohol hol consumption may inform the diagno- use. Although many of these medical sis of the patient’s presenting condition, consequences tend to be concentrated in and it may alert clinicians to the need to persons with severe alcohol dependence, advise patients whose alcohol consump- even the use of alcohol in the range of tion might adversely affect their use of 20-40 grams of absolute alcohol per day medications and other aspects of their is a risk factor for accidents, injuries, and treatment. Screening also offers the many social problems5, 6. opportunity for practitioners to take preventative measures that have proven Many factors contribute to the develop- effective in reducing alcohol-related risks. ment of alcohol-related problems. Ignorance of drinking limits and of the risks associated with excessive alcohol consumption are major factors. Social and environmental influences, such as customs and attitudes that favor heavy drinking, also play important roles. Of utmost importance for screening, however, is the fact that people who are not dependent on alcohol may stop or reduce their alcohol consumption with appropriate assistance and effort. Once dependence has developed, cessation of alcohol consumption is more difficult and often requires specialized treatment. Although not all hazardous drinkers become dependent, no one develops alcohol dependence without having engaged for some time WHY SCREEN FOR ALCOHOL USE? I 7

Figure 1

Effects of High-Risk Drinking Alcohol dependence. Aggressive,irrational behaviour. Memory loss. Arguments. Violence. Depression. Nervousness. Premature aging. Drinker's nose. Cancer of throat and mouth .

Weakness of heart muscle. Frequent colds. Reduced Heart failure. Anemia. resistance to infection. Impaired blood clotting. Increased risk of pneumonia. Breast cancer.

Liver damage. Vitamin deficiency. Bleeding. Severe inflammation of the stomach. Vomiting. Trembling hands. Diarrhea. Malnutrition. Tingling fingers. Numbness. Painful nerves.

Inflammation of the pancreas. Ulcer.

Impaired sensation leading to falls. In men: Impaired sexual performance. In women: Risk of giving birth to deformed, retarded babies or low birth weight babies.

Numb, tingling toes. Painful nerves.

High-risk drinking may lead to social, legal, medical, domestic, job and financial problems. It may also cut your lifespan and lead to accidents and death from drunk- en driving. 8 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST The Context of Alcohol Screening

hile this manual focuses on using the To these should be added groups consid- WAUDIT to screen for alcohol con- ered by a WHO Expert Committee7 to be sumption and related risks in primary care at high risk of developing alcohol-related medical settings, the AUDIT can be effec- problems: middle-aged males, adolescents, tively applied in many other contexts as migrant workers, and certain occupation- well. In many cases procedures have al groups (such as business executives, already been developed and used in these entertainers, sex workers, publicans, and settings. Box 1 summarizes information seamen). The nature of the risk differs by about the settings, screening personnel, age, gender, drinking context, and drinking and target groups considered appropriate pattern, with sociocultural factors playing for a screening programme using the AUDIT. an important role in the definition and Murray9 has argued that screening might expression of alcohol-related problems6. be conducted profitably with: general hospital patients, especially those with disorders known to be associated with alcohol dependence (e.g., pancreatitis, cirrhosis, gastritis, tuberculosis, neurological disorders, cardiomyopathy); persons who are depressed or who attempt suicide; other psychiatric patients; patients attending casualty and emergency services; patients attending general practitioners; vagrants; prisoners; and those cited for legal offences connected with drinking (e.g., driving while intoxicated, public intoxication). THE CONTEXT OF ALCOHOL SCREENING I 9

Box 1

Personnel, Settings and Groups Considered Appropriate for a Screening Programme Using the AUDIT

Setting Target Group Screening Personnel

Primary care clinic Medical patients Nurse, social worker

Emergency room Accident victims, Physician, nurse, or staff Intoxicated patients, trauma victims

Physician’s Room Medical patients General practitioner, Surgery family physician or staff

General Hospital wards Patients with Internist, staff Out-patient clinic hypertension, heart disease, gatrointestinal or neurological disorders

Psychiatric hospital Psychiatric patients, Psychiatrist, staff particularly those who are suicidal

Court, jail, prison DWI offenders Officers, Counsellors violent criminals

Other health-related Persons demonstrating Health and human facilities impaired social or service workers occupational functioning (e.g. marital discord, child neglect, etc.)

Military Services Enlisted men and officers Medics

Work place Workers, especially those Employee assistance staff Employee assistance having problems with Programme productivity, absenteeism or accidents 10 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST Development and Validation of the AUDIT

he AUDIT was developed and evaluat- This comparative field study was conducted Ted over a period of two decades, and in six countries (Norway, Australia, Kenya, it has been found to provide an accurate Bulgaria, Mexico, and the United States measure of risk across gender, age, and of America). cultures1, 2,10. Box 2 describes the conceptual domains and item content of the AUDIT, The method consisted of selecting items which consists of 10 questions about that best distinguished low-risk drinkers recent alcohol use, alcohol dependence from those with harmful drinking. Unlike symptoms, and alcohol-related problems. previous screening tests, the new instrument As the first screening test designed specif- was intended for the early identification of ically for use in primary care settings, the hazardous and harmful drinking as well as AUDIT has the following advantages: alcohol dependence (alcoholism). Nearly 2000 patients were recruited from a variety Cross-national standardization: the of health care facilities, including specialized AUDIT was validated on primary health alcohol treatment centers. Sixty-four percent care patients in six countries1,2. It is the were current drinkers, 25% of whom were only screening test specifically designed diagnosed as alcohol dependent. for international use; Identifies hazardous and harmful alco- Participants were given a physical exami- hol use, as well as possible dependence; nation, including a blood test for standard Brief, rapid, and flexible; blood markers of alcoholism, as well as an Designed for primary health care workers; extensive interview assessing demographic characteristics, medical history, health Consistent with ICD-10 definitions of alco- complaints, use of alcohol and drugs, psy- hol dependence and harmful alcohol use3,4; chological reactions to alcohol, problems Focuses on recent alcohol use. associated with drinking, and family histo- In 1982 the World Health Organization ry of alcohol problems. Items were select- asked an international group of investiga- ed for the AUDIT from this pool of ques- tors to develop a simple screening instru- tions primarily on the basis of correlations ment2. Its purpose was to identify persons with daily alcohol intake, frequency of with early alcohol problems using proce- consuming six or more drinks per drinking dures that were suitable for health systems episode, and their ability to discriminate in both developing and developed countries. hazardous and harmful drinkers. Items were The investigators reviewed a variety of also chosen on the basis of face validity, self-report, laboratory, and clinical proce- clinical relevance, and coverage of relevant dures that had been used for this purpose conceptual domains (i.e., alcohol use, alco- in different countries. They then initiated a hol dependence, and adverse consequences cross-national study to select the best fea- of drinking). Finally, special attention in item tures of these various national approaches selection was given to gender appropriate- to screening1. ness and cross-national generalizability. DEVELOPMENT AND VALIDATION OF THE AUDIT I 11

Box 2

Domains and Item Content of the AUDIT

Domains Question Item Content Number

Hazardous 1 Frequency of drinking Alcohol 2 Typical quantity Use 3 Frequency of heavy drinking

Dependence 4 Impaired control over drinking Symptoms 5 Increased salience of drinking 6 Morning drinking

Harmful 7 Guilt after drinking Alcohol 8 Blackouts Use 9 Alcohol-related injuries 10 Others concerned about drinking

Sensitivities and specificities of the select- ment samples1, a cut-off value of 8 points ed test items were computed for multiple yielded sensitivities for the AUDIT for vari- criteria (i.e., average daily alcohol consump- ous indices of problematic drinking that tion, recurrent intoxication, presence of at were generally in the mid 0.90’s. least one dependence symptom, diagnosis Specificities across countries and across of alcohol abuse or dependence, and self- criteria averaged in the 0.80’s. perception of a drinking problem). Various cut-off points in total scores were consid- The AUDIT differs from other self-report ered to identify the value with optimal screening tests in that it was based on sensitivity (percentage of positive cases data collected from a large multinational that the test correctly identified) and sample, used an explicit conceptual- specificity (percentage of negative cases statistical rationale for item selection, that the test correctly identified) to distin- emphasizes identification of hazardous guish hazardous and harmful alcohol use. drinking rather than long-term dependence In addition, validity was also computed and adverse drinking consequences, and against a composite diagnosis of harmful focuses primarily on symptoms occurring use and dependence. In the test develop- during the recent past rather than “ever.” 12 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Once the AUDIT had been published, the cultures11, 12, 13, 15, 19, 22, 23, 24, suggesting developers recommended additional vali- that the AUDIT has fulfilled its promise as dation research. In response to this request, an international screening test. a large number of studies have been conducted to evaluate its validity and reliabil- Although evidence on women is somewhat ity in different clinical and community limited11, 12, 24, the AUDIT seems equally samples throughout the world10. At the appropriate for males and females. The recommended cut-off of 8, most studies effect of age has not been systematically have found very favorable sensitivity and analyzed as a possible influence on the usually lower, but still acceptable, speci- AUDIT, but one study19 found low sensi- ficity, for current ICD-10 alcohol use dis- tivity but high specificity in patients above orders10,11,12 as well as the risk of future age 65. The AUDIT has proven to be harm12. Nevertheless, improvements in accurate in detecting alcohol dependence detection have been achieved in some in university students18. cases by lowering or raising the cut-off score by one or two points, depending In comparison to other screening tests, on the population and the purpose of the AUDIT has been found to perform the screening programme11,12. equally well or at a higher degree of accu- racy10, 11, 25, 26 across a wide variety of cri- A variety of subpopulations have been stud- terion measures. Bohn, et al.27 found a ied, including primary care patients 13, 14, 15, strong correlation between the AUDIT emergency room cases11, drug users16, and the MAST (r=.88) for both males and the unemployed17, university students18, females, and correlations of .47 and .46 elderly hospital patients19, and persons of for males and females, respectively, on a low socio-economic status20. The AUDIT covert content alcoholism screening test. has been found to provide good discrimi- A high correlation coefficient (.78) was nation in a variety of settings where these also found between the AUDIT and the populations are encountered. A recent CAGE in ambulatory care patients26. systematic review21 of the literature has AUDIT scores were found to correlate well concluded that the AUDIT is the best with measures of drinking consequences, screening instrument for the whole range attitudes toward drinking, vulnerability to of alcohol problems in primary care, as alcohol dependence, negative mood states compared to other questionnaires such as after drinking, and reasons for drinking27. the CAGE and the MAST. It appears that the total score on the AUDIT reflects the extent of alcohol involvement Cultural appropriateness and cross- along a broad continuum of severity. national applicability were important considerations in the development of the Two studies have considered the relation AUDIT1, 2. Research has been conducted between AUDIT scores and future indica- in a wide variety of countries and tors of alcohol-related problems and more DEVELOPMENT AND VALIDATION OF THE AUDIT I 13

global life functioning. In one study17, the It was concluded that the ER is an ideal likelihood of remaining unemployed over setting for implementing alcohol screen- a two year period was 1.6 times higher ing with the AUDIT. Similarly, Piccinelli, et for individuals with scores of 8 or more al.15 evaluated the AUDIT as a screening on the AUDIT than for comparable per- tool for hazardous alcohol intake in prima- sons with lower scores. In another study28, ry care clinics in Italy. AUDIT performed AUDIT scores of ambulatory care patients well in identifying alcohol-related disorders predicted future occurrence of a physical as well as hazardous use. Ivis, et al.22 disorder, as well as social problems relat- incorporated the AUDIT into a general ed to drinking. AUDIT scores also predict- population telephone survey in Ontario, ed health care utilization and future risk Canada. of engaging in hazardous drinking28. Since the AUDIT User’s Manual was first Several studies have reported on the reli- published in 198930, the test has fulfilled ability of the AUDIT18, 26, 29. The results many of the expectations that inspired its indicate high internal consistency, suggest- development. Its reliability and validity have ing that the AUDIT is measuring a single been established in research conducted in construct in a reliable fashion. A test-retest a variety of settings and in many different reliability study29 indicated high reliability nations. It has been translated into many (r=.86) in a sample consisting of non-haz- languages, including Turkish, Greek, Hindi, ardous drinkers, cocaine abusers, and German, Dutch, Polish, Japanese, French, alcoholics. Another methodological study Portuguese, Spanish, Danish, Flemish, was conducted in part to investigate the Bulgarian, Chinese, Italian, and Nigerian effect of question ordering and wording dialects. Training programmes have been changes on prevalence estimates and developed to facilitate its use by physicians internal consistency reliability22. Changes and other health care providers31, 32 (see in question ordering and wording did not Appendix E). It has been used in primary affect the AUDIT scores, suggesting that care research and in epidemiological within limits, researchers can exercise studies for the estimation of prevalence some flexibility in modifying the order in the general population as well as spe- and wording of the AUDIT items. cific institutional groups (e.g., hospital patients, primary care patients). Despite With increasing evidence of the reliability the high level of research activity on the and validity of the AUDIT, studies have AUDIT, further research is needed, espe- been conducted using the test as a cially in the less developed countries. prevalence measure. Lapham, et al.23 Appendix A provides guidelines for con- used it to estimate prevalence of alcohol tinued research on the AUDIT. use disorders in emergency rooms (ERs) of three regional hospitals in Thailand. 14 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST Administration Guidelines

he AUDIT can be used in a variety of The patient is not intoxicated or in need Tways to assess patients’ alcohol use, of emergency care at the time; but programmes to implement it should The purpose of the screening be clearly first set guidelines that consider the stated in terms of its relevance to the patient’s circumstances and capacities. patient’s health status; Additionally, care must be taken to tell The information patients need to patients why questions about alcohol use understand the questions and respond are being asked and to provide informa- accurately be provided; and tion they need to make appropriate responses. A decision must be made Assurance is given that the patient’s whether to administer the AUDIT orally or responses will remain confidential. as a written, self-report questionnaire. Health workers should try to establish Finally, consideration must be given to these conditions before the AUDIT is using skip-outs to shorten the screening given. When these conditions are not pre- for greater efficiency. This section recom- sent or when a patient is resistant, the mends guidelines on such issues of Clinical Screening Procedures (discussed in administration. Appendix D) may provide an alternative course of action. Considering the Patient Choose the best possible circumstance for All patients should be screened for alco- administering the AUDIT. For patients hol use, preferably annually. The AUDIT requiring emergency treatment or in great can be administered separately or com- pain, it is best to wait until their medical bined with other questions as part of a condition has stabilized and they have general health interview, a lifestyle ques- become accustomed to the health setting tionnaire, or medical history. If health where administration of the AUDIT is to workers screen only those they consider take place. Look for signs of alcohol or most likely to have a “drinking problem”, drug intoxication. Patients who have alco- the majority of patients who drink exces- hol on their breath or who appear intoxi- sively will be missed. However, it is impor- cated may be unreliable respondents. tant to consider the condition of the Consider screening at a later time. If this patients when asking them to answer is not possible, make note of these find- questions about alcohol use. To increase ings on the patient's record. the patient’s receptivity to the questions and the accuracy of responding, it is When presented in a medical context important that: with genuine concern for the patient’s well being, patients are almost always The interviewer (or presenter of the sur- open and responsive to the AUDIT ques- vey) be friendly and non-threatening; tions. Moreover, most patients answer the questions honestly. Even when excessive ADMINISTRATION GUIDELINES I 15

drinkers underestimate their consump- This statement should be followed by a tion, they often qualify on the AUDIT description of the types of alcoholic bev- scoring system as positive for alcohol risk. erages typically consumed in the country or region where the patient lives (e.g., “By Introducing the AUDIT alcoholic beverages we mean your use of wine, beer, vodka, sherry, etc.”) If neces- Whether the AUDIT is used as an oral sary, include a description of beverages interview or a written questionnaire, it is that may not be considered alcoholic, recommended that an explanation be (e.g. cider, low alcohol beer, etc.). With given to patients of the content of the patients whose alcohol consumption is questions, the purpose for asking them, prohibited by law, culture, or religion and the need for accurate answers. The (e.g., youths, observant Muslims), acknowl- following are illustrative introductions for edgment of such prohibition and encour- oral delivery and written questionnaires: agement of candor may be needed. For example, “I understand others may think “Now I am going to ask you some ques- you should not drink alcohol at all, but it tions about your use of alcoholic bever- is important in assessing your health to ages during the past year. Because alco- know what you actually do.” hol use can affect many areas of health (and may interfere with certain medica- Patient instructions should also clarify the tions), it is important for us to know how meaning of a standard drink. Questions much you usually drink and whether you 2 and 3 of AUDIT ask about “drinks con- have experienced any problems with your sumed”. The meaning of this word differs drinking. Please try to be as honest and from one nation and culture to another. as accurate as you can be.” It is important therefore to mention the most common alcoholic beverages likely “As part of our health service it is impor- to be consumed and how much of each tant to examine lifestyle issues likely to constitutes a drink (approximately 10 grams affect the health of our patients. This of pure ethanol). For example, one bottle information will assist in giving you the of beer (330 ml at 5% ethanol), a glass best treatment and highest possible stan- of wine (140 ml at 12% ethanol), and a dard of care. Therefore, we ask that you shot of spirits (40 ml at 40% ethanol) complete this questionnaire that asks represent a standard drink of about 13 g about your use of alcoholic beverages of ethanol. Since the types and amounts during the past year. Please answer as of alcoholic drinks will vary according to accurately and honestly as possible. Your culture and custom, the alcohol content health worker will discuss this issue with of typical servings of beer, wine and spirits you. All information will be treated in must be determined to adapt the AUDIT strict confidence. to particular settings. See Appendix C. 16 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Oral Administration vs. Whatever decision is made, it must be con- Self-report Questionnaire sistent with implementation plans to establish a comprehensive screening programme. The AUDIT may be administered either as an oral interview or as a self-report ques- The AUDIT questions and responses are tionnaire. Each method carries its own presented in Box 4 in a format suggested advantages and disadvantages that must for an oral interview. Appendix B gives an be weighed in light of time and cost con- example of the self-report questionnaire. straints. The relative merits of using the Adaptation should be made to needs of AUDIT as an interview vs. the self-report the particular screening programme as well questionnaire are summarized in Box 3. as the alcoholic beverages most commonly The cognitive capacities (literacy, forgetful- consumed in that society. Appendix C pro- ness) and level of cooperation (defensive- vides guidelines for translation and adapta- ness) of the patient should be considered. tion to national and local conditions. If the expectation is that primary care providers will manage all the care that If the AUDIT is administered as an interview, patients will receive for their alcohol prob- it is important to read the questions as lems, an interview may have advantages. written and in the order indicated. By fol- However, if the provider’s responsibility lowing the exact wording, better compa- will be limited to offering brief advice to rability will be obtained between your patients who screen positive and referring results and those obtained by other inter- more severe cases to other services, the viewers. Most of the questions in the questionnaire method may be preferable. AUDIT are phrased in terms of “how

Box 3

Advantages of Different Approaches to AUDIT Administration

Questionnaire Interview Takes less time Allows clarification of ambiguous answers Easy to administer Can be administered to patients with poor reading skills Suitable for computer administration and scoring May produce more accurate answers Allows seamless feedback to patient and initiation of brief advice ADMINISTRATION GUIDELINES I 17

Box 4

The Alcohol Use Disorders Identification Test: Interview Version Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks”. Place the correct answer number in the box at the right.

1. How often do you have a drink containing alco- 6. How often during the last year have you needed hol? a first drink in the morning to get yourself going after a heavy drinking session? (0) Never [Skip to Qs 9-10] (1) Monthly or less (0) Never (2) 2 to 4 times a month (1) Less than monthly (3) 2 to 3 times a week (2) Monthly (4) 4 or more times a week (3) Weekly (4) Daily or almost daily

2. How many drinks containing alcohol do you have 7. How often during the last year have you had a on a typical day when you are drinking? feeling of guilt or remorse after drinking? (0) 1 or 2 (0) Never (1) 3 or 4 (1) Less than monthly (2) 5 or 6 (2) Monthly (3) 7, 8, or 9 (3) Weekly (4) 10 or more (4) Daily or almost daily

3. How often do you have six or more drinks on one 8. How often during the last year have you been occasion? unable to remember what happened the night before because you had been drinking? (0) Never (1) Less than monthly (0) Never (2) Monthly (1) Less than monthly (3) Weekly (2) Monthly (4) Daily or almost daily (3) Weekly Skip to Questions 9 and 10 if Total Score (4) Daily or almost daily for Questions 2 and 3 = 0

4. How often during the last year have you found 9. Have you or someone else been injured as a that you were not able to stop drinking once you result of your drinking? had started? (0) No (0) Never (2) Yes, but not in the last year (1) Less than monthly (4) Yes, during the last year (2) Monthly (3) Weekly (4) Daily or almost daily

5. How often during the last year have you failed to 10. Has a relative or friend or a doctor or another do what was normally expected from you health worker been concerned about your drink- because of drinking? ing or suggested you cut down? (0) Never (0) No (1) Less than monthly (2) Yes, but not in the last year (2) Monthly (4) Yes, during the last year (3) Weekly (4) Daily or almost daily

Record total of specific items here If total is greater than recommended cut-off, consult User’s Manual. 18 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

often” symptoms occur. Provide the However, it eliminates the information patient with the response categories given obtained from the interview format. for each question (for example, “Never,” Moreover, it presumes literacy and ability “Several times a month,” “Daily”). When a of the patient to perform the required response option has been chosen, it is actions. It may also require less time on useful to probe during the initial ques- the part of health workers, if patients can tions to be sure that the patient has complete the process alone. With time at selected the most accurate response (for a premium for both health workers and example, “You say you drink several times patients, ways of shortening the screening a week. Is this just on weekends or do process merit consideration. you drink more or less every day?”). Shortening the Screening Process If responses are ambiguous or evasive, Administered either orally or as a question- continue asking for clarification by repeat- naire, the AUDIT can usually be completed ing the question and the response options, in two to four minutes and scored in a asking the patient to choose the best few seconds. However, for many patients one. At times answers are difficult to it is unnecessary to administer the complete record because the patient may not drink AUDIT because they drink infrequently, on a regular basis. For example, if the moderately, or abstain entirely from alco- patient was drinking excessively during the month before an accident, but not hol. The interview version of the AUDIT prior to that time, then it will be difficult (Box 4) provides two opportunities to skip to characterize the “typical” drinking questions for such patients. If the patient sought by the question. In these cases it answers in response to Question 1 that no is best to record the amount of drinking drinking has occurred during the last year, and related symptoms for the heaviest the interviewer may skip to Questions 9-10, drinking period in the past year, making responses to which may indicate past prob- note of the fact that this may be atypical lems with alcohol. Patients who score points or transitory for that individual. on these questions may be considered at risk if they begin to drink again, and should be Record answers carefully, making note of advised to avoid alcohol. It is recommended any special circumstances, additional infor- that this skip out instruction only be used mation, and clinical observations. Often with the interview or computer-assisted patients will provide the interviewer with formats of the AUDIT. useful comments about their drinking that can be valuable in the interpretation of the A second opportunity to shorten AUDIT AUDIT total score. screening occurs after Question 3 has been answered. If the patient scored 0 Administering the AUDIT as a written ques- on Questions 2 and 3, the interviewer tionnaire or by computer eliminates many may skip to Questions 9-10 because the of the uncertainties of patient responses by patient’s drinking has not exceeded the allowing only specific choices. low risk drinking limits. SCORING AND INTERPRETATION I 19 Scoring and Interpretation

he AUDIT is easy to score. Each of the More detailed interpretation of a patient’s Tquestions has a set of responses to total score may be obtained by determin- choose from, and each response has a ing on which questions points were score ranging from 0 to 4. In the interview scored. In general, a score of 1 or more format (Box 4) the interviewer enters the on Question 2 or Question 3 indicates score (the number within parentheses) consumption at a hazardous level. Points corresponding to the patient’s response scored above 0 on questions 4-6 (espe- into the box beside each question. In cially weekly or daily symptoms) imply the the self-report questionnaire format presence or incipience of alcohol depen- (Appendix B), the number in the column dence. Points scored on questions 7-10 of each response checked by the patient indicate that alcohol-related harm is should be entered by the scorer in the already being experienced. The total extreme right-hand column. All the response score, consumption level, signs of depen- scores should then be added and recorded dence, and present harm all should play in the box labeled “Total”. a role in determining how to manage a patient. The final two questions should Total scores of 8 or more are recom- also be reviewed to determine whether mended as indicators of hazardous and patients give evidence of a past problem harmful alcohol use, as well as possible (i.e., “yes, but not in the past year”). alcohol dependence. (A cut-off score of Even in the absence of current hazardous 10 will provide greater specificity but at drinking, positive responses on these the expense of sensitivity.) Since the items should be used to discuss the need effects of alcohol vary with average body for vigilance by the patient. weight and differences in metabolism, establishing the cut off point for all In most cases the total AUDIT score will women and men over age 65 one point reflect the patient’s level of risk related to lower at a score of 7 will increase sensi- alcohol. In general health care settings tivity for these population groups. and in community surveys, most patients Selection of the cut-off point should be will score under the cut-offs and may be influenced by national and cultural stan- considered to have low risk of alcohol- dards and by clinician judgment, which related problems. A smaller, but still sig- also determine recommended maximum nificant, portion of the population is like- consumption allowances. Technically ly to score above the cut-offs but record speaking, higher scores simply indicate most of their points on the first three greater likelihood of hazardous and questions. A much smaller proportion harmful drinking. However, such scores can be expected to score very high, with may also reflect greater severity of alcohol points recorded on the dependence-relat- problems and dependence, as well as a ed questions as well as exhibiting alco- greater need for more intensive treatment. hol-related problems. As yet there has been insufficient research to establish 20 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

precisely a cut-off point to distinguish AUDIT scores of 20 or above clearly hazardous and harmful drinkers (who warrant further diagnostic evaluation would benefit from a brief intervention) for alcohol dependence. from alcohol dependent drinkers (who In the absence of better research these should be referred for diagnostic evalua- guidelines should be considered tenta- tion and more intensive treatment). This tive, subject to clinical judgment that is an important question because screen- takes into account the patient’s medical ing programmes designed to identify condition, family history of alcohol prob- cases of alcohol dependence are likely to lems and perceived honesty in respond- find a large number of hazardous and ing to the AUDIT questions. harmful drinkers if the cut-off of 8 is used. These patients need to be man- While use of the 10-question AUDIT aged with less intensive interventions. In questionnaire will be sufficient for the general, the higher the total score on the vast majority of patients, special circum- AUDIT, the greater the sensitivity in find- stances may require a clinical screening ing persons with alcohol dependence. procedure. For example, a patient may be resistant, uncooperative, or unable to Based on experience gained in a study of respond to the AUDIT questions. If fur- treatment matching with persons who ther confirmation of possible dependence had a wide range of alcohol problem is warranted, a physical examination pro- severity, AUDIT scores were compared cedure and laboratory tests may be used, with diagnostic data reflecting low, medi- as described in Appendix D. um and high degrees of alcohol dependence. It was found that AUDIT scores in the range of 8-15 represented a medium level of alcohol problems whereas scores of 16 and above represented a high level of alcohol problems33. On the basis of experience gained from the use of the AUDIT in this and other research, it is suggested that the following interpretation be given to AUDIT scores:

Scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking. Scores between 16 and 19 suggest brief counseling and continued monitoring. HOW TO HELP PATIENTS I 21 How to Help Patients

sing the AUDIT to screen patients is only Uthe first step in a process of helping Box 5 reduce alcohol-related problems and risks.

Health care workers must decide what Advise Patients services they can provide to patients who not to Drink score positive. Once a positive case has When operating a vehicle or been identified, the next step is to provide machinery an appropriate intervention that meets the When pregnant or considering needs of each patient. Typically, alcohol pregnancy screening has been used primarily to find “cases” of alcohol dependence, who are If a contraindicated medical then referred to specialized treatment. In condition is present recent years, however, advances in screen- After using certain medications, ing procedures have made it possible to such as sedatives, analgesics, screen for risk factors, such as hazardous and selected antihypertensives drinking and harmful alcohol use. Using the AUDIT Total Score, there is a simple way to provide each patient with an appropri- third level, Zone III, is suggested by AUDIT ate intervention, based on the level of risk. scores in the range of 16 to 19. Harmful and hazardous drinking can be managed While this discussion will focus on helping by a combination of simple advice, brief those patients who score positive on the counseling and continued monitoring, AUDIT, sound preventative practice also with further diagnostic evaluation indicated calls for reporting screening results to if the patient fails to respond or is suspected those who score negative. These patients of possible alcohol dependence. The fourth should be reminded about the benefits of risk level is suggested by AUDIT scores in low risk drinking or abstinence and told excess of 20. These patients should be not to drink in certain circumstances, referred to a specialist for diagnostic evalu- such as those mentioned in Box 5. ation and possible treatment for alcohol dependence. If these services are not avail- Four levels of risk are shown in Box 6. able, these patients can be managed in Zone I refers to low risk drinking or absti- primary care, especially when mutual help nence. The second level, Zone II, consists organizations are able to provide commu- of alcohol use in excess of low-risk guide- nity-based support. Using a stepped-care lines5, and is generally indicated when the approach, patients can be managed first at AUDIT score is between 8 and 15. A brief the lowest level of intervention suggested intervention using simple advice and patient by their AUDIT score. If they do not respond education materials is the most appropriate to the initial intervention, they should be course of action for these patients. The referred to the next level of care. 22 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Box 6

Risk Level Intervention AUDIT score*

Zone I Alcohol Education 0-7

Zone II Simple Advice 8-15

Zone III Simple Advice plus Brief Counseling and Continued Monitoring 16-19

Zone IV Referral to Specialist for Diagnostic 20-40 Evaluation and Treatment

*The AUDIT cut-off score may vary slightly depending on the country’s drinking patterns, the alcohol content of standard drinks, and the nature of the screening program. Clinical judgment should be exercised in cases where the patient’s score is not consistent with other evidence, or if the patient has a prior history of alcohol dependence. It may also be instructive to review the patient’s responses to individual questions dealing with dependence symptoms (Questions 4, 5 and 6) and alcohol-related problems (Questions 9 and 10). Provide the next highest level of intervention to patients who score 2 or more on Questions 4, 5 and 6, or 4 on Questions 9 or 10.

Brief interventions for hazardous and A number of randomized controlled trials harmful drinking constitute a variety of have evaluated the efficacy of this approach, activities characterized by their low inten- showing consistently positive benefits for sity and short duration. They range from 5 minutes of simple advice about how to Box 7 reduce hazardous drinking to several ses- sions of brief counseling to address more 36 complicated conditions . Intended to Elements of Brief provide early intervention, before or soon Interventions after the onset of alcohol-related problems, brief interventions consist of feedback of Present screening results screening data designed to increase moti- Identify risks and discuss conse- vation to change drinking behaviour, as quences well as simple advice, health education, Provide medical advice skill building, and practical suggestions. Solicit patient commitment Over the last 20 years procedures have been developed that primary care practi- Identify goal—reduced drinking or tioners can readily learn and practice to abstinence address hazardous and harmful drinking. Give advice and encouragement These procedures are summarized in Box 7. HOW TO HELP PATIENTS I 23

patients who are not dependent on alco- CIDI39 or the SCAN40. The alcohol sections hol36, 37, 38. A companion WHO manual, of these interviews require 5 to 10 minutes Brief Intervention for Hazardous and to complete. Harmful Drinking: A Manual for Use in Primary Care, provides more information The Tenth revision of the International on this approach. Classification of Diseases (ICD-10)4 provides detailed guidelines for the diagnosis Referral to alcohol specialty care is common of acute alcohol intoxication, harmful use, among those primary care practitioners alcohol dependence syndrome, withdrawal who do not have competency in treating state, and related medical and neuropsy- alcohol use disorders and where specialty chiatric conditions. The ICD-10 criteria for care is available. Consideration must be the alcohol dependence syndrome are given to the willingness of patients to described in Box 8. accept referral and treatment. Many patients underestimate the risks associat- Detoxification may be necessary for some ed with drinking; others may not be pre- patients. Special attention should be paid pared to admit and address their depen- to patients whose AUDIT responses indi- dence. A brief intervention, adapted to cate daily consumption of large amounts the purpose of initiating a referral using of alcohol and/or positive responses to data from a clinical examination and questions indicative of possible depen- blood tests, may help to address patient dence (questions 4-6). Enquiry should be resistance. Follow-up with the patient made as to how long a patient has gone and the specialty provider may also since having an alcohol-free day and any assure that the referral is accepted and prior experience of withdrawal symp- treatment is received. toms. This information, a physical examination, and laboratory tests (see Clinical Diagnosis is a necessary step following Screening Procedures, Appendix D) may high positive scoring on the AUDIT, since inform a judgment of whether to recom- the instrument does not provide suffi- mend detoxification. Detoxification cient basis for establishing a manage- should be provided for patients likely to ment or treatment plan. While persons experience moderate to severe withdraw- associated with the screening programme al not only to minimize symptoms, but should have a basic familiarity with the also to prevent or manage seizures or criteria for alcohol dependence, a quali- delirium, and to facilitate acceptance of fied professional who is trained in the therapy to address dependence. While diagnosis of alcohol use disorders4 should inpatient detoxification may be necessary conduct this assessment. The best in a small number of severe cases, ambu- method of establishing a diagnosis is latory or home detoxification can be used through the use of a standardized, struc- successfully with the majority of less tured, psychiatric interview, such as the severe cases. 24 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Box 8

ICD-10 Criteria for the Alcohol Dependence Syndrome Three or more of the following manifestations should have occurred together for at least 1 month or, if persisting for periods of less than 1 month, should have occurred together repeatedly within a 12-month period: a strong desire or sense of compulsion to consume alcohol; impaired capacity to control drinking in terms of its onset, termination, or levels of use, as evidenced by: alcohol being often taken in larger amounts or over a longer period than intended; or by a persistent desire to or unsuccessful efforts to reduce or control alcohol use; a physiological withdrawal state when alcohol use is reduced or ceased, as evidenced by the characteristic withdrawal syndrome for alcohol, or by use of the same (or close- ly related) substance with the intention of relieving or avoiding withdrawal symptoms; evidence of tolerance to the effects of alcohol, such that there is a need for significantly increased amounts of alcohol to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of alcohol; preoccupation with alcohol, as manifested by important alternative pleasures or interests being given up or reduced because of drinking; or a great deal of time being spent in activities necessary to obtain, take, or recover from the effects of alcohol; persistent alcohol use despite clear evidence of harmful consequences, as evidenced by continued use when the individual is actually aware, or may be expected to be aware, of the nature and extent of harm. (p.57, WHO, 1993)

Medical management or treatment of Because the diagnosis and treatment of alcohol dependence has been described alcohol dependence have developed as a in previous WHO publications41. A variety specialty within the mainstream of med- of treatments for alcohol dependence ical care, in most countries primary care have been developed and found practitioners are not trained or experienced effective42. Significant advances have in its diagnosis or treatment. In such cases been made in pharmacotherapy, family primary care screening programmes must and social support therapy, relapse pre- establish protocols for referring patients vention, and behaviour-oriented skills suspected of being alcohol dependent training interventions. who need further diagnosis and treatment. PROGRAMME IMPLEMENTATION I 25 Programme Implementation

lcohol screening and appropriate place. However, both policy and proce- Apatient care have been recognized dural decisions will be required. widely as essential to good medical practice. Like many medical practices that It is generally helpful to involve in plan- achieve such recognition, there is often a ning the staff who will participate in or failure to implement effective technolo- be affected by the screening operation. gies within organized systems of health Participation of persons with diverse per- care. Implementation requires special spectives, experience, and responsibilities efforts to assure compliance of individual is most likely to identify obstacles and practitioners, overcome obstacles, and create ways to remove or surmount adapt procedures to special circum- them. In addition, the involvement of stances. Research into implementation staff in planning yields a sense of owner- has begun to produce useful guidelines ship over the resulting implementation for effective implementation43, 44. Four plan. This is likely to increase the commit- major elements have emerged as critical ment of individuals and the group to fol- to success: low the plan and make improvements along the way that will assure success. planning; A partial list of implementation issues on training; which planning is helpful are presented in Box 9. An implementation plan should monitoring; and receive formal approval at whatever feedback. level(s) required before training begins.

Planning is necessary not only to design Training is essential to preparing a health the alcohol screening programme but care organization to implement its plan- also to engage participants in the “own- ning. However, training without a man- ership” of the programme. Every primary agement decision to implement a screen- care practice is unique. Each has estab- ing programme is likely to be ineffective lished special procedures suited to its and even counter-productive. A training physical setting, social and cultural envi- package has been developed31 to sup- ronment, patient population, economics, port implementation of AUDIT screening staffing structure, and even individual and brief intervention (See Appendix E). personalities. Thus, adapting AUDIT Training should address the critical issues screening to each practice situation must of why screening is important, what con- involve fitting its essential elements into ditions should be identified, how to use this context in a way that is most likely to the AUDIT, and optimal procedures to achieve sustained success. If screening for assure success. Effective training should other health conditions and risk factors is involve staff in a detailed discussion of already part of standard practice, those their functions and responsibilities within procedures may provide a useful starting the new programme plan. It should also 26 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

Box 9

Implementation Questions Which patients will be screened? How often will patients be screened? How will screening be coordinated with other activities? Who will administer the screen? What provider and patient materials will be used? Who will interpret results and help the patient? How will medical records be maintained? What follow-up actions will be taken? How will patients needing screening be identified? When during the patient’s visit will screening be done? What will be the sequence of actions? How will instruments and materials be obtained, stored, and managed? How will follow-up be scheduled?

provide supervised practice in administer- the only recourse is total abstinence. ing the AUDIT instrument and any other Some people who hold these beliefs may procedures planned (e.g., brief interven- find a programme of screening and brief tions, referral, etc.). intervention to be fruitless or threatening. It is critical that special care is taken In some countries many people, even to allow such issues to be addressed medical staff, are accustomed to think openly, frankly, and with attention to the only of alcohol dependence when other best scientific evidence. With sound issues related to alcohol are raised. It is explanation and patience, most medical not uncommon for health workers to staff will either understand the value of believe that people with alcohol prob- screening or suspend judgment until lems cannot be helped unless they “hit experience allows a determination of its bottom” and seek treatment, and that value. PROGRAMME IMPLEMENTATION I 27

Monitoring is an effective way to improve the quality of screening programme implementation. There are various ways of measuring the success of an alcohol screening programme. The number of screenings performed may be compared to the number of people presenting who should have been screened under the established policy, producing a percentage of screening success. Recording and totaling the percentage of patients who screen positive is also a useful measure that encourages staff by establishing the need for the service. Determining the percentage of patients who received the appropriate intervention (brief intervention, referral, diagnosis, etc.) for their AUDIT score is a further measure of programme performance. Finally, a small sample of patients who had screened positive six to twelve months before might be surveyed to provide at least anecdotal evidence of outcome success. Re-administration of the AUDIT can serve as the basis for measuring quantitative outcomes.

Whatever criteria of success are employed, frequent feedback to all par- ticipating staff is essential for results to contribute to enhanced programme performance in the early periods of implementation. Written reports and discussion at regular staff meetings will also provide occasions at which staff can address any problems that may be inter- fering with success. 28 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST Appendix A Research Guidelines for the AUDIT

he AUDIT was developed on the basis screening procedures, careful attention Tof an extensive six-nation validation should be given to the alcohol-related trial1, 2. Additional research has been phenomena to be detected or predicted. conducted to evaluate its accuracy and Emphasis should be given to the assess- utility in different settings, populations, ment of initial risk levels, harmful use, and cultural groups10. To provide further and alcohol dependence. The demands guidance to this process, it is recom- of methodologically sound validation mended that health researchers use the require the use of independent diagnos- AUDIT to answer some of the following tic criteria, which themselves have been questions: validated. Two instruments that may be useful for this purpose are the Does AUDIT predict future alcohol Composite International Diagnostic problems as well as the patient’s Interview (CIDI) and the Schedules for response to brief intervention and more Clinical Assessment in Neuropsychiatry intensive treatment? This can be evalu- (SCAN)39, 40. Both of these interviews ated by conducting repeated AUDIT provide independent verification of a screening on the same individual. Total variety of alcohol use disorders accord- scores can be correlated with various ing to ICD-10 and other diagnostic sys- indicators of future symptomatology. It tems. The test could be improved by would be desirable to know, for exam- focusing on more carefully defined risk ple, whether AUDIT assesses alcohol- groups and more specific alcohol-related related problems along a continuum of problems. Specification of cut-off points severity, whether severity scores increase is needed for target populations whose progressively among individuals who problems are to be the focus of screen- continue to drink heavily, and whether ing with AUDIT, especially persons with scores diminish significantly following harmful use and alcohol dependence. advice, counseling, and other types of intervention. A screening test should What are the practical barriers to not be conceived in isolation from screening with the AUDIT? Important intervention and treatment. It must be constraints on screening tests are evaluated in terms of its impact on the imposed by cost considerations and by morbidity and mortality of the popula- the acceptability of screening to both tion at risk. Its contribution to secondary health professionals and the intended and primary prevention is therefore target populations. When a screening dependent on the availability of effec- test is expensive, the results of a screen- tive intervention strategies. ing programme may not justify its cost. This is also true when the procedure is What is the sensitivity, specificity and time consuming, overly invasive, or oth- predictive power of the AUDIT in differ- erwise offensive to the target group. ent risk groups using different validation This type of process evaluation should criteria? In future evaluations of the AUDIT be conducted with AUDIT. APPENDIX A I 29

Can the AUDIT be scored to produce can be compared to the distribution of separate assessments of hazardous use, scores within the general population. harmful use, and alcohol dependence? What is the concurrent validity of the If screening can be differentiated into AUDIT items and total scores when these separate domains, it may prove compared with different “objective” useful for the purpose of evaluating indicators of alcohol-related problems, different educational and treatment such as blood alcohol level, biochemical approaches to secondary prevention. markers of heavy drinking, public Alternatively, the AUDIT Total Score records of alcohol-related problems, provides a general measure of severity and observational data obtained from that may be useful for treatment persons knowledgeable about the matching and stepped-care approaches patient's drinking behaviour. To the to clinical management (i.e., providing extent that verbal report procedures the lowest level of intervention that may have intrinsic limitations, it would addresses the patient’s immediate be useful to evaluate under what cir- needs). If the patient does not respond, cumstances AUDIT results are biased or the next higher “step” is provided. otherwise invalid. Procedures to increase Although AUDIT scores in the range of the accuracy of AUDIT should also be 8 to 19 seem appropriate to brief inter- investigated. ventions, further research is needed to find the optimal cut-off points that are How acceptable is the AUDIT to prima- most appropriate for simple advice, ry care workers? How can screening brief counseling, and more intensive procedures best be taught in the con- treatment. text of educating health professionals? How extensively are screening proce- How can the AUDIT be used in epidemi- dures using AUDIT applied once stu- ological research? The AUDIT may have dents or health workers are trained? applications as an epidemiological tool in surveys of health clinics, health service systems, and general population samples. The AUDIT was developed as an international instrument but it could also be used to compare samples drawn from different national and cultural groups, with respect to the nature and prevalence of hazardous drinking, harmful drinking, and alcohol dependence. Before this is done it would be useful to develop norms for various risk levels so that individual and group scores 30 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST Appendix B Suggested Format for AUDIT Self-Report Questionnaire

n some settings there may be advan- interventions. Such material, however, Itages to administering the AUDIT as a should be sufficiently coded so as not to questionnaire completed by the patient compromise patients' honesty in answer- rather than as an oral interview. Such an ing AUDIT questions. approach often saves time, costs less, and may produce more accurate answers by the patient. These advantages may also result from administration via computer. The AUDIT questionnaire format presented in Box 10 may be useful for such purposes.

Use of the skip outs provided in the oral interview (Box 4 on page 17) is likely to be too difficult for patients to follow in a paper administration. However, they are easily achieved automatically in com- puterized applications.

Administrators are encouraged to add illustrations of local, commonly available beverages in standard drink amounts. Question 3 may require modification (to 4 or 5 drinks), depending on the number of standard drinks required to total 60 grams of pure ethanol (See Appendix C).

Scoring instructions: Each response is scored using the numbers at the top of each response column. Write the appropriate number associated with each answer in the column at the right. Then add all numbers in that column to obtain the Total Score.

Space at the bottom of the form may be designated “For Office Use Only” to contain instructions or places to document actions taken by health workers who administer the AUDIT or provide brief APPENDIX B I 31

Box 10

The Alcohol Use Disorders Identification Test: Self-Report Version PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest. Place an X in one box that best describes your answer to each question.

Questions 0 1 2 3 4

1. How often do you have Never Monthly 2-4 times 2-3 times 4 or more a drink containing alcohol? or less a month a week times a week

2. How many drinks containing 1 or 2 3 or 4 5 or 6 7 to 9 10 or more alcohol do you have on a typical day when you are drinking?

3. How often do you have six or Never Less than Monthly Weekly Daily or more drinks on one monthly almost occasion? daily

4. How often during the last Never Less than Monthly Weekly Daily or year have you found that you monthly almost were not able to stop drinking daily once you had started?

5. How often during the last Never Less than Monthly Weekly Daily or year have you failed to do monthly almost what was normally expected of daily you because of drinking?

6. How often during the last year Never Less than Monthly Weekly Daily or have you needed a first drink monthly almost in the morning to get yourself daily going after a heavy drinking session?

7. How often during the last year Never Less than Monthly Weekly Daily or have you had a feeling of guilt monthly almost or remorse after drinking? daily

8. How often during the last year Never Less than Monthly Weekly Daily or have you been unable to remem- monthly almost ber what happened the night daily before because of your drinking?

9. Have you or someone else No Yes, but Yes, been injured because of not in the during the your drinking? last year last year

10.Has a relative, friend, doctor, or No Yes, but Yes, other health care worker been not in the during the concerned about your drinking last year last year or suggested you cut down?

Total 32 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST Appendix C Translation and Adaptation to Specific Languages, Cultures and Standards

n some cultural settings and linguistic for these questions in order to fit the Igroups, the AUDIT questions cannot be most common drink sizes and alcohol translated literally. There are a number of strength in your country. sociocultural factors that need to be taken into account in addition to seman- The recommended low-risk drinking level tic meaning. For example, the drinking set in the brief intervention manual and customs and beverage preferences of cer- used in the WHO study on brief inter- tain countries may require adaptation of ventions is no more than 20 grams of questions to conform to local conditions. alcohol per day, 5 days a week (recom- mending 2 non-drinking days). With regard to translation into other languages, it should be noted that the AUDIT How to Calculate the Content questions have been translated into Spanish, of Alcohol in a Drink Slavic, Norwegian, French, German, Russian, The alcohol content of a drink depends on Japanese, Swahili, and several other lan- the strength of the beverage and the vol- guages. These translations are available by ume of the container. There are wide varia- writing to the Department of Mental tions in the strengths of alcoholic bever- Health and Substance Dependence, World ages and the drink sizes commonly used in Health Organization, 1211 Geneva 27, different countries. A WHO survey45 indi- Switzerland. Before attempting to trans- cated that beer contained between 2% late AUDIT into other languages, interest- and 5% volume by volume of pure alcohol, ed individuals should consult with WHO wines contained 10.5% to 18.9%, spirits Headquarters about the procedures to be varied from 24.3% to 90%, and cider from followed and the availability of other 1.1% to 17%. Therefore, it is essential to translations. adapt drinking sizes to what is most common at the local level and to know roughly What is a Standard Drink? how much pure alcohol the person con- In different countries, health educators sumes per occasion and on average. and researchers employ different definitions of a standard unit or drink because Another consideration in measuring the of differences in the typical serving sizes amount of alcohol contained in a stan- in that country. For example, dard drink is the conversion factor of ethanol. That allows you to convert any 1 standard drink in Canada: 13.6 g of volume of alcohol into grammes. For each pure alcohol milliliter of ethanol, there are 0.79 grammes 1 s drink in the UK: 8 g of pure ethanol. For example, 1 s drink in the USA: 14 g 1 s drink in Australia or New Zealand: 10 g 1 can beer (330 ml) at 5% x (strength) 1 s drink in Japan: 19.75 g 0.79 (conversion factor) = 13 grammes of ethanol In the AUDIT, Questions 2 and 3 assume 1 glass wine (140 ml) at 12% x that a standard drink equivalent is 10 grams 0.79 = 13.3 grammes of ethanol of alcohol. You may need to adjust the 1 shot spirits (40 ml) at 40% x number of drinks in the response categories 0.79 = 12.6 grammes of ethanol. APPENDIX D I 33 Appendix D Clinical Screening Procedures

clinical examination and laboratory Hand tremor. This should be estimated Atests can sometimes be helpful in the with the arms extended anteriorly, half detection of chronic harmful alcohol use. bent at the elbows, with the hands Clinical screening procedures have been rotated toward the midline. developed for this purpose34. These include tremor of the hands, the appear- Tongue tremor. This should be evaluat- ance of blood vessels in the face, and ed with the tongue protruding a short changes observed in the mucous mem- distance beyond the lips, but not too branes (e.g., conjunctivitis) and oral cavity excessively. (e.g., glossitis), and elevated liver enzymes. Hepatomegaly. Hepatic changes should Only qualified health workers should be evaluated both in terms of volume conduct the examination. Several of and consistency. Increased volume can the items require explanation in order be gaged in terms of finger breadths to make a reliable diagnosis. below the costal margin. Consistency can be rated as normal, firm, hard, or Conjunctival injection. The condition of very hard. the conjunctival tissue is evaluated on the basis of the extent of capillary Several laboratory tests are useful in the engorgement and scleral jaundice. detection of alcohol misuse. Serum Examination is best conducted in clear gamma-glutamyl transferase (GGT), car- daylight by asking the patient to direct bohydrate deficient transferrin (CDT), his gaze upward and then downward mean corpuscular volume (MCV) of red while pulling back the upper and lower blood cells and serum aspartate amino eye-lids. Under normal conditions, the transferase (AST) are likely to provide, at normal pearly whiteness is widely dis- relatively low cost, a possible indication tributed. In contrast, capillary engorge- of recent excessive alcohol consumption. ment is reflected in the appearance of It should be noted that false positives can burgundy-coloured vascular elements occur when the individual uses drugs and the appearance of a greenish-yel- (such as barbiturates) that induce GGT, or low tinge to the sclera. has hand tremor because of nervousness, neurological disorder, or nicotine depen- Abnormal skin vascularization. This is dence. best evaluated by examination of the face and neck. These areas often give evidence of fine wiry arterioles that appear as a reddish blush. Other signs of chronic alcohol ingestion include the appearance of 'goose-flesh" on the neck and yellowish blotches on the skin. 34 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST Appendix E Training Materials for AUDIT

raining materials and other resources Thave been developed to teach AUDIT screening and brief intervention tech- niques. These include videos, instructor's manuals, and leaflets. Resources that can be used to obtain training to use the AUDIT to screen for alcohol problems are listed below:

Anderson, P. Alcohol and primary health care. World Health Organization, Regional Publications, European Series no. 64, 1996.

Project NEADA (Nursing Education in Alcohol and Drug Abuse), consists of a 30 minute video entitled Alcohol Screening and Brief Intervention and an Instructor's Manual31 with lecture material, role playing exercises, guidelines for group discussions, and learner activity assignments. Available through the U.S. National Clearinghouse on Alcohol and Drug Information: www.health.org or call 1-800-729-6686.

Alcohol risk assessment and intervention (ARAI) package. Ontario, College of Family Physicians of Canada, 1994.

Sullivan, E., and Fleming, M. A Guide to Substance Abuse Services for Primary Care Clinicians, Treatment Improvement Protocol Series, 24, U.S. Department of Health and Human Services, Rockville, MD 20857, 1997. REFERENCES I 35 References

1. Saunders, J.B., Aasland, O.G., Babor, Policy and the Public Good. Oxford T.F., de la Fuente, J.R. and Grant, University Press, 1994. M. Development of the Alcohol Use Disorders Identification Test (AUDIT): 7. World Health Organization. Problems WHO collaborative project on early related to alcohol consumption, detection of persons with harmful Report of a WHO Expert Committee. alcohol consumption. II. Addiction, 88, Tech. Report Series 650, Geneva, 791-804, 1993. WHO, 1980.

2. Saunders, J.B., Aasland, O.G., 8. Kreitman, N. Alcohol consumption Amundsen, A. and Grant, M. Alcohol and the prevention paradox. British consumption and related problems Journal of Addiction 81, 353-363, among primary health care patients: 1986 WHO Collaborative Project on Early Detection of Persons with Harmful 9. Murray, R.M. Screening and early Alcohol Consumption I. Addiction, detection instruments for disabilities 88, 349-362, 1993. related to alcohol consumption. In: Edwards, G., Gross, M.M., Keller, M., Moser, J. & Room, R. (Eds) Alcohol- 3. Babor, T., Campbell, R., Room, R. and Related Disabilities. WHO Offset Pub. Saunders, J.(Eds.) Lexicon of Alcohol No. 32. Geneva, World Health and Drug Terms, World Health Organization, 89-105, 1977. Organization, Geneva, 1994.

10. Allen, J.P., Litten, R.Z., Fertig, J.B. and 4. World Health Organization. The ICD- Babor, T. A review of research on the 10 Classification of Mental and Alcohol Use Disorders Identification Behavioural Disorders: Diagnostic cri- Test (AUDIT). Alcoholism: Clinical and teria for research, World Health Experimental Research 21(4): 613- Organization, Geneva, 1993. 619, 1997.

5. Anderson, P., Cremona, A., Paton, A., 11. Cherpitel, C.J. Analysis of cut points Turner, C. & Wallace, P. The risk of alco- for screening instruments for alcohol hol. Addiction 88, 1493-1508, 1993. problems in the emergency room. Journal of Studies on Alcohol 6. Edwards, G., Anderson, P., Babor, T.F., 56:695-700, 1995. Casswell, S., Ferrence, R., Geisbrecht, N., Godfrey, C., Holder, H., Lemmens, 12. Conigrave, K.M., Hall, W.D., P., Makela, K., Midanik, L., Norstrom, Saunders, J.B., The AUDIT question- T., Osterberg, E., Romelsjo, A., Room, naire: choosing a cut-off score. R., Simpura, J., Skog., O. Alcohol Addiction 90:1349-1356, 1995. 36 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

13. Volk, R.J., Steinbauer, J.R., Cantor, 19. Powell, J.E. and McInness, E. Alcohol S.B. and Holzer, C.E. The Alcohol Use use among older hospital patients: Disorders Identification Test (AUDIT) as Findings from an Australian study. a screen for at-risk drinking in primary Drug and Alcohol Review 13:5-12, care patients of different racial/ethnic 1994. backgrounds. Addiction 92(2):197- 206, 1997. 20. Isaacson, J.H., Butler, R., Zacharek, M. and Tzelepis, A. Screening with 14. Rigmaiden, R.S., Pistorello, J., Johnson, the Alcohol Use Disorders J., Mar, D. and Veach, T.L. Addiction Identification Test (AUDIT) in an medicine in ambulatory care: inner-city population. Journal of Prevalence patterns in internal medi- General Internal Medicine 9:550-553, cine. Substance Abuse 16:49-57, 1995. 1994.

15. Piccinelli, M., Tessari, E., Bortolomasi, 21. Fiellin, D.A., Carrington, R.M. and M., Piasere, O., Semenzin, M. Garzotto, O’Connor, P.G. Screening for alcohol N. and Tansella, M. Efficacy of the problems in primary care: a systemat- alcohol use disorders identification ic review. Archives of Internal test as a screening tool for hazardous Medicine 160: 1977-1989, 2000. alcohol intake and related disorders in primary care: a validity study. British 22. Ivis, F.J., Adlaf, E.M. and Rehm, J. Medical Journal 314(8) 420-424, 1997. Incorporating the AUDIT into a general population telephone survey: a 16. Skipsey, K., Burleson, J.A. and methodological experiment. Drug & Kranzler, H.R. Utility of the AUDIT for Alcohol Dependence 60:97-104, the identification of hazardous or 2000. harmful drinking in drug-dependent patients. Drug and Alcohol 23. Lapham, S.C., Skipper, B.J., Brown, P., Dependence 45:157-163, 1997. Chadbunchachai, W., Suriyawongpaisal, 17. Claussen, B. and Aasland, O.G. The P. and Paisarnsilp, S. Prevalence of Alcohol Use Disorders Identification alcohol use disorders among emer- Test (AUDIT) in a routine health exam- gency room patients in Thailand. ination of long-term unemployed. Addiction 93(8), 1231-1239, 1998. Addiction 88:363-368, 1993. 24. Steinbauer, J.R., Cantor, S.B., Holder, 18. Fleming, M.F., Barry, K.L. and C.E. and Volk, R.J. Ethnic and sex MacDonald, R. The alcohol use disor- bias in primary care screening tests ders identification test (AUDIT) in a col- for alcohol use disorders. Annals of lege sample. International Journal of Internal Medicine 129: 353-362, the Addictions 26:1173-1185, 1991. 1998. REFERENCES I 37

25. Clements, R. A critical evaluation of 31. McRee, B., Babor, T.F. and Church, several alcohol screening instruments O.M. Instructor's Manual for Alcohol using the CIDI-SAM as a criterion Screening and Brief Intervention. measure. Alcoholism: Clinical and Project NEADA, University of Experimental Research 22(5):985- Connecticut School of Nursing, 1991. 993, 1998. 32. Gomel, M. and Wutzke, S. Phase III 26. Hays, R.D., Merz, J.F. and Nicholas, R. World Health Organization Response burden, reliability, and Collaborative Study. Procedures validity of the CAGE, Short MAST, Manual Strand III, Part 1. Dept. of and AUDIT alcohol screening mea- Psychiatry, University of Sydney, New sures. Behavioral Research Methods, South Wales, 1995. Instruments & Computers 27:277- 280, 1995. 33. Miller, W.R., Zweben, A., DiClemente, C.C. and Rychtarik, R.G. 27. Bohn, M.J., Babor, T.F. and Kranzler, Motivational enhancement therapy H.R. The Alcohol Use Disorders manual: A clinical research guide for Identification Test (AUDIT): Validation therapists treating individuals with of a screening instrument for use in alcohol abuse and dependence. medical settings. Journal of Studies Project MATCH Monograph Series, on Alcohol 56:423-432, 1995. Vol. 2. Rockville MD: NIAAA, 1992. 28. Conigrave, K.M., Saunders, J.B. and 34. Babor, T.F., Weill, J., Treffardier, M. Reznik, R.B. Predictive capacity of the and Benard, J.Y. Detection and diag- AUDIT questionnaire for alcohol-relat- nosis of alcohol dependence using ed harm. Addiction 90:1479-1485, the Le Go grid method. In: Chang N 1995. (Ed.) Early identification of alcohol 29. Sinclair, M., McRee, B. and Babor, T.F. abuse. NIAAA Research Monograph Evaluation of the Reliability of AUDIT. 17, DHHS Pub. No. (ADM) 85-1258, University of Connecticut School of Washington, D.C. USGPO, 1985; Medicine, Alcohol Research Center, 321-338. (unpublished report), 1992. 35. Saunders, J.B. and Aasland, O.G. 30. Babor, T.F., de la Fuente, J.R., WHO Collaborative Project on Saunders, J. and Grant, M. AUDIT Identification and Treatment of The Alcohol Use Disorders Persons with Harmful Alcohol Identification Test: Guidelines for Use Consumption. Geneva, Switzerland, in Primary Health Care. World Health Organization WHO/MNH/DAT 89.4, World Health (Unpublished Document Organization, Geneva, 1989. WHO/MNH/DAT/86.3), 1987. 38 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

36. Bien, T.H., Miller, W.R. and Tonigan, 41. Heather, N. Treatment approaches S. Brief intervention for alcohol prob- to alcohol problems. Copenhagen, lems: a review. Addiction 88:315-336, WHO Regional Office for Europe, 1993. 1995 (WHO Regional Publications, European Series, No. 65). 37. Kahan, M., Wilson, L. and Becker, L. Effectiveness of physician-based inter- 42. National Institute on Alcohol Abuse ventions with problem drinkers: A and Alcoholism. 10th Special Report review. Canadian Medical Association to the U.S. Congress on Alcohol and Journal, 152(6):851-859, 1995. Health. Rockville, MD, 2000.

38. Wilk, A.I., Jensen, N.M. and 43. Richmond, R.L. and Anderson, P. Havighurst, T.C. Meta-analysis of ran- Research in general practice for smok- domized control trials addressing ers and excessive drinkers in Australia brief interventions in heavy alcohol and the UK. III. Dissemination of drinkers. Journal of General Internal interventions. Addiction 89, 49-62, Medicine, 12:274-283, 1997. 1994.

39. Robins, L.N., Wing, J., Wittchen, 44. Babor, T.F. and Higgins-Biddle, J.C. H.U., Helzer, J.E., Babor, T.F., Burke, Alcohol screening and brief interven- J., Farmer, A., Jablenski, A., Pickens, tion: dissemination strategies for R, Regier, D., Sartorius, N. and Towle, medical practice and public health. L. The Composite International Addiction 95(5):677-686, 2000. Diagnostic Interview: An epidemiological instrument suitable for use in 45. Finnish Foundation for Alcohol conjunction with different diagnostic Studies. International Statistics on systems and in different cultures. Alcoholic Beverages: Production, Archives of General Psychiatry, Trade and Consumption 1950-1972. 45:1069-1077, 1988. Helsinki, Finnish Foundation for Alcohol Studies, 1977. 40. Wing, J.K., Babor, T., Brugha, T., Burke, J., Cooper, J.E., Giel, R., Jablenski, A., Regier, D. and Sartorius, N. SCAN - Schedules for Clinical Assessment in Neuropsychiatry. Archives of General Psychiatry 47:589-593, 1990. NOTES I 39 Notes 40 I AUDIT I THE ALCOHOL USE DISORDERS IDENTIFICATION TEST